- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Facility | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $75.86 / $676.08
| Professional | | $37.15 | $75.86 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $114.82 / $114.82
| Professional | | $104.71 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $131.83
| Facility | | $75.86 | $75.86 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $134.90 / $223.87
| Professional | | $75.86 | $134.90 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $131.83 / $602.56
| Facility | | $75.86 | $131.83 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $58.88 / $125.89
| Professional | | $38.90 | $58.88 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $316.23
| Professional | | $128.82 | $128.82 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $295.12 / $316.23
| Professional | | $162.18 | $295.12 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $69.18 / $134.90
| Facility | | $44.67 | $69.18 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $58.88 / $93.33
| Professional | | $42.66 | $58.88 | $93.33 |